Integrating the social determinants of health into graduate medical education training: a scoping review

Background The social determinants of health (SDH) play a key role in the health of individuals, communities, and populations. Academic institutions and clinical licensing bodies increasingly recognize the need for healthcare professionals to understand the importance of considering the SDH to engage with patients and manage their care effectively. However, incorporating relevant skills, knowledge, and attitudes relating to the SDH into curricula must be more consistent. This scoping review explores the integration of the SDH into graduate medical education training programs. Methods A systematic search was performed of PubMed, Ovid MEDLINE, ERIC, and Scopus databases for articles published between January 2010 and March 2023. A scoping review methodology was employed, and articles related to training in medical or surgical specialties for registrars and residents were included. Pilot programs, non-SDH-related programs, and studies published in languages other than English were excluded. Results The initial search produced 829 articles after removing duplicates. The total number of articles included in the review was 24. Most articles were from developed countries such as the USA (22), one from Canada, and only one from a low- and middle-income country, Kenya. The most highly represented discipline was pediatrics. Five papers explored the inclusion of SDH in internal medicine training, with the remaining articles covering family medicine, obstetrics, gynecology, or a combination of disciplines. Longitudinal programs are the most effective and frequently employed educational method regarding SDH in graduate training. Most programs utilize combined teaching methods and rely on participant surveys to evaluate their curriculum. Conclusion Applying standardized educational and evaluation strategies for SDH training programs can pose a challenge due to the diversity of the techniques reported in the literature. Exploring the most effective educational strategy in delivering these concepts and evaluating the downstream impacts on patient care, particularly in surgical and non-clinical specialties and low- and middle-income countries, can be essential in integrating and creating a sustainable healthcare force.


Introduction
The World Health Organization (WHO) defines the social determinants of health (SDH) as "the conditions in which people are born, grow, live, work, and age, that affect a wide range of health and quality of life outcomes." These conditions are brought about by the nature in which resources, finances, and power are distributed locally, nationally, and globally and may include economic policies and systems, development agendas, social norms, social policies, and political systems [1].SDH can have a significant impact on individual and population health.Studies have demonstrated that marginalized individuals and communities suffering discrimination have noticeably poorer health outcomes [2]..
There has been a clarion call to integrate SDH concepts for doctors seeking postgraduate training to equip future healthcare professionals with the appropriate competencies to tackle SDH-related factors at the patient and community level [3][4][5].A critical understanding of the causes and impacts of SDH by doctors is needed to provide effective healthcare while offering adequate stewardship of limited resources and promoting health equity of the populations they serve [6].Orienting medical training towards SDH is a significant step to equip physicians with the understanding, proficiencies, and attitudes needed to begin to address health inequalities [7].
Medical education regarding the SDH is crucial for future medical practitioners [8].Besides potentially enhancing health outcomes for individual patients, physicians tackling these disparities will adopt the initiatives calling for changes to influence population and community health [9][10][11].Thus, understanding social determinants of health requires a perspective shift for graduate learners, with the desired educational outcome being transformative learning [12,13].
Despite a growing understanding of the importance of integrating SDH into health professional curricula, the optimum approach to incorporating SDH teaching into undergraduate and graduate training curricula has yet to be clarified.A comprehensive guide for SDH teaching strategies would promote consistency in graduate training.A previous scoping review explored the inclusion of SDH in undergraduate medical curricula.The study highlighted the benefits of longitudinal curricula with community involvement in developing retainable knowledge and skills regarding SDH for medical students [14].In 2019, a scoping review exploring the graduate curriculum interventions focused on SDH objectives concluded the insufficient physician training regarding SDH covers Canada only [15]..This scoping review was performed to explore the extent of integration of SDH in graduate medical education curricula globally.The study objective was to explore the structure, content, training strategies, and evaluation methods used in incorporating SDH into training qualified doctors seeking higher medical training.

Methods
The scoping review was performed by searching four relevant databases -PubMed, Ovid MEDLINE, ERIC, and Scopus.The process was undertaken by standard scoping review methodology, including identifying the research question, identifying relevant studies, selecting studies, charting the data, and collating, summarizing, and reporting the results [16].

i. Formulation of the research question
All authors formulated the research question, guided by the WHO's definition of social determinants of health [1].The overall question: What has been published on the topic of the integration of SDH into graduate medical education curricula?Specifically, the research question focused on the content of the SDH teaching in the graduate medical curriculum, their presentation, teaching strategies, and program evaluation.It aimed to identify any gaps in the available literature to guide future research.

ii. Identification of relevant studies, including the data sources and search strategy
Authors searched PubMed, Ovid MEDLINE, ERIC, and Scopus in March 2023.Individual search strategies were developed for each database, and searches were run for each database (Table 1).The search strategy was comprehensive to capture the diversity of the potential SDH integrated into the graduate medical education curricula.PRISMA-ScR guidelines [17,18] were followed, as illustrated in (Fig. 1).The study population consisted of medical professionals (doctors) in any discipline undertaking postgraduate training, including specialty trainees, residents, fellows, and registrars; the concept was the content of the curriculum used for teaching the SDH, with the context being graduate medical schools and training health facilities and institutes globally.

iii. Identifying relevant studies
Two authors (DO, NN) reviewed relevant articles after the initial removal of duplicates by exporting the references to Mendeley Reference Manager [19]; articles were analyzed using Rayyan [20], an online software that helps with a blinded screening of articles.Two authors (DO, NN) then independently screened the titles and abstracts without limiting the articles' publication dates, population, and study locations.The remaining articles underwent full-text screening, and a third author was called to arbitrate where there were differences in screening outcomes.

iv. Inclusion and exclusion criteria
Articles were deemed eligible for inclusion if they focused on graduate SDH curricula, including fellows, registrars, trainees, and residents.Studies had to contain structural curricula to qualify for inclusion.Articles published in English between January 2012 and March 2023 were included in the current study.If the program did not intend to integrate the SDH in graduate medical education or did not indicate a mechanism for evaluating the curriculum, they were excluded from this review.Also, the following exclusion criteria were applied: undergraduate programs, reports, systematic reviews, pilot programs, unstructured programs, programs not focusing on SDH teaching, programs not in English, internship studies, and studies that focused on allied health programs such as nursing, public health, global health, dentistry, and pharmacy.

xxii. Charting the data
The main characteristics of each graduate SDH medical curriculum were detailed, including the discipline integrating the program, the program title, length, educational methods, teaching concepts, and methods of curriculum evaluation.In this stage, data from the selected articles were extracted to a Microsoft Excel sheet, and key information about the authors and year of publication was included.
vi. Quality assessment tool.
Two reviewers (DO, NN) performed an independent quality assessment for each article.The Medical Education Research Study Quality Instrument (MERSQI) [21] was selected for quality appraisal of the included articles.The appraisal tools assessed the articles over six domains -study design, sampling, type of data, validity of the evaluation, data synthesis, and outcome.All the  included articles had a score of 9 and above, which is acceptable.
Only 28 articles met the inclusion criteria.The next step was a full examination of the 28 articles that met the inclusion criteria and whose focus was oriented toward the contents of the SDH in graduate medical education.At this point, we removed seven articles as they did not meet the quality assessment criteria.
A total of 21 articles met the inclusion criteria and were included in the review.A hand search through the references of the included articles yielded another four studies; three were deemed eligible for inclusion, and one pilot program was excluded.The final number of articles included in the review was 24.

Summary of the graduate SDH training programs
Of the 24 programs included in the current scoping review, 22 were from graduate residency programs in the United States of America(USA), one from Canada, and one from a residency program in Kenya.Almost 50% (n = 12) of the articles were based on pediatric graduate curricula, while nearly 21% (n = 5) were from internal medicine programs, as indicated in Table 2.
The structure of the programs related to SDH varied across a range of thematic areas.A total of five courses had a focus on home visits and different community healthcare interventions [23,30,31,40,41], while another set of 10 programs was in the form of case-based workshops on a variety of topics such as prison healthcare, housing issues locating pharmacies and follow-up of patients after discharge [24-26, 28, 29, 32, 34, 39, 43, 45] Lastly, nine programs focused on health advocacy topics, such as opportunities to integrate SDH at community health clinics, housing, education, and legal issues, integration of health disparities to clinical practices and equity, diversity, and inclusion [22,27,[33][34][35][36][37][38]44].

Programs presentation methods
The approach to presenting the graduate SDH training and learning activities varied.All the programs used participatory learning, "where the learners are actively participating instead of being passive listeners, " as an educational strategy in combination with other teaching modalities.Eleven programs combined participatory learning with community placement and didactic teaching [23-25, 28, 31, 33, 34, 36, 40-42].Another six programs relied on a participatory approach, with community placement and no formal lectures [27,35,36,[43][44][45].Three programs integrated didactic teaching and a participatory approach with no community engagement [29,37,38].Another set of four programs included participatory learning only, requiring participant engagement, such as information gathering, group discussions, and activities [22,26,32,39].
Five programs evaluated the participants' affective learning, including their awareness, interest, and empathy combined with their level of knowledge regarding the SDH within the local context [23,29,31,42,44].Another three programs used affective learning assessment solely [33,35,41].One program adopted a comprehensive assessment on the three levels, including participants' attitudes, knowledge, and performance [43].Another program incorporated knowledge and performance as an evaluation tool [38], and one used the candidate's performance as the main evaluation aspect [34].Additionally, 13 programs only used the participants' knowledge level as an evaluation indicator [22, 24-28, 30, 32, 37, 39-41, 45]..

Discussion
This work details a scoping review of literature relating to incorporating the SDH in graduate medical training curricula.Notably, of a total of 24 included articles, 22 programs were implemented in the USA medical schools 45], with one program in Canada [44] and only one from a low-and middle-income country (Kenya) [22].The evaluation of the programs varied on different levels; most programs performed post-learning evaluation only for the participants, and only one program added the patient's perspective on the quality of service provided.The evaluation modules used need more clarity in reporting.The programs with extended training over the years reported a more favorable impact on the knowledge and the participant's skills regarding SDH concepts.Participants favored training programs that blinded academic knowledge with community placement.
Paediatric training programs took the lead in training healthcare professionals in SDH.Other specialties, such as internal medicine, family medicine, and psychiatry, needed to be more proactive in integrating the SDH into their curriculum.Incorporating SDH concepts for        all healthcare training is essential for weaving socially accountable healthcare into healthcare systems [46].. Participants rated the SDH programs with a multi-year longitudinal structure highly.This finding agrees with other studies suggesting that spiral training programs improve trainees' community integration, mentorship, confidence, knowledge in evidence-based medicine, patient-centred care, and reflective practice [47][48][49][50].. Our study found heterogeneity in each program's content, as SDH factors can differ from one geographical location to another.The WHO study states that educators should apply a local context approach to tackle this issue [51]..All the programs' teaching strategies involved the participants in the teaching process, so-called "participatory learning." The programs integrated academic knowledge with community placement and significantly impacted the comprehension of SDH concepts and their application in real-life situations.These findings correlate with studies emphasizing that combining theoretical learning with community engagement will enhance participants' ability to cultivate an understanding of the core principles of the taught subject [52][53][54][55][56][57].. Finally, most programs evaluated the participants' knowledge level and confidence in recognizing SDHrelated factors pre-and post, or post-program only.The reported evaluation outcomes included improved knowledge, awareness, and trust in dealing with diverse and underserved communities.Only one program interviewed the patients' guardians and evaluated the care received by the trained physician [33].This finding highlights a gap in program evaluation and the need to identify standardized criteria to monitor the success of SDH teaching in postgraduate curricula [58]..

Study limitations and strengths
The number of published articles demonstrating the implementation of SDH training in postgraduate programs is limited.This limitation is likely a significant under-representation of the innovation and scope of SDH integration into postgraduate curricula and again highlights the need for more high-quality literature assessing the effective incorporation, delivery, and assessment of SDH competencies.The scope of articles available in English primarily limited our study.The study focused on the programs including SDH teaching as a separate module not included with public health or global health.Our study is constrained by the unavailability of data from specific databases, which has restricted the scope of our research.Despite these limitations, our study has several strengths.Our study represents a pioneering effort in the field by conducting a comprehensive analysis of integrating SDH into graduate medical training programs.The significance of this research lies in its ability to shed light on the current state of these programs and identify critical areas for improvement.This study displays the heterogeneity of evaluation for such training programs and the deficiency in following the downstream impact of this training on patients' health.These findings further support questions raised by medical education experts such as Sharma et al. (2018), who explained the importance of SDH teaching and the role of educators and training institutions yet criticized the focus on integration rather than evaluation [59]..

Implications for practice and future research
Our review has identified several future research implications; there needs to be more representation of the published literature about the topic in general and from low-and middle-income countries.The different expression of the SDH training programs by the developed countries' training institutions may be because of the influence of The Accreditation Council for Graduate Medical Education (ACGME).The ACGME approves complete and independent medical education programs in the United States and Canada.The ACGME standards include addressing health equity and enhancing cultural competency through the taught curriculum of the accredited graduate program, which compels medical institutions to integrate SDH into their curricula [60,61].This shows the critical influence accrediting bodies have on the content of medical curricula.As the United Nations (UN) stated in 2015, low-and middle-income countries face triple the burden of health issues and, therefore, creating a well-trained healthcare force and robust health system performance will decrease social disparities [62,63].

Conclusion
Integrating SDH into graduate medical education curricula is a dynamic and evolving area of research and practice.While the literature highlights the growing recognition of the importance of SDH education, it also reveals gaps in standardized curriculum development, assessment strategies, and long-term evaluation.Providing a multi-level structure approach for the methodology, implementation, and evaluation of SDH training programs will allow training bodies and institutions to integrate SDH concepts more effectively and produce a transparent blueprint for others to follow.Addressing these gaps will ensure that medical graduates are prepared to overcome complex SDH in healthcare.

Fig. 1
Fig. 1 PRISMA flow diagram for the systematic scoping review of the SDH post-graduate training program *Consider, if feasible to do so, reporting the number of records identified from each database or register searched (rather than the total number across all databases/registers). **If automation tools were used, indicate how many records were excluded by a human and how many were excluded by automation tools.From: Page MJ, McKenzie JE, Bossuyt PM, Boutron I, Hoffmann TC, Mulrow CD, et al.The PRISMA 2020 statement:an updated guideline for reporting systematic reviews.BMJ 2021;372:n71.doi: https:// doi.org/ 10. 1136/ bmj.n71.For more information, visit:(38)

Table 1
Search Strategy for the Databases regarding the SDH Postgraduate Training

Table 2
Number of articles in each Post-graduate Speciality Program

Table 3
Study summary of SDH training programs